An undernourished mother is likely to give birth to an undernourished child, resulting in a poor start in life and setting up a life cycle of child undernutrition. Households with pregnant women and children under 24 months of age are at ‘high risk’ of undernutrition. For public health services to catch them right from conception, and regularly follow the mothers/caregivers intensively in the first 1000 days of life for nutritional interventions, is crucial to establish early patterns of positive behavioral change for prevention of maternal and child undernutrition, say India’s nutrition experts.
Every fourth under-five child in India is undernourished. The rate of child undernutrition increases steadily between 0-24 months and then stabilizes from 2 years onwards. India's nutrition experts suggest focusing on a child's first 1000 days of life – starting right from conception, 270 days of foetal growth during pregnancy and 730 days up to their second birthday, is the golden ‘window of opportunity’ for reducing child undernutrition. Therefore, reaching all pregnant women soon after diagnosis, newborns to 6 months, children between 6-24 months, is the most crucial. Experts also believe that, at any given point in a population of about 1000, there would be approximately 50 households in the ’higher risk group’ of undernutrition.
Nutrition experts estimate that every month around 6 new individuals (approximately two pregnant women, 2 newborn children, 2 children crossing six months) are expected to be added as well as exit from the pool of beneficiaries. This unique '2+2+2 approach' would help in mapping and streamlining focus on nutrition early on after the identification of the group ’at risk of undernutrition’.
An augmented focus on these smaller groups of 50 persons rather than 1000 at one time would make it easier for frontline ICDS and healthcare workers like Anganwadi workers (AWWs) and accredited social health activists (ASHAs) to deliver essential maternal-child health-nutrition services and undertake targeted door-to-door interpersonal counselling in home environment. Behavioral change communication activities such as interpersonal counselling, if done right early and regularly, can propel desired undernutrition-preventing behaviors.
Being among the grassroots ICDS and healthcare workers that drive the public health service delivery system in the country, the Anganwadi and ASHA workers help materialize a range of activities, including conducting household surveys and listing under-twos, screening children for malnutrition, promoting early initiation and exclusive breastfeeding, appropriate feeding starting at age of 6 months, hygiene and sanitation, mobilizing for routine antenatal services, routine child immunization, distributing iron-folic acid and calcium tablets to pregnant/lactating women, counseling mothers/families on quantity and quality of diets for adequate weight gain, creating awareness and mobilizing people for immunization and antenatal services.
"The first thousand days of life are important for the promotion of optimal growth and development of the brain. In fact, 80 percent of brain development takes place in the first 1000 days of life. For healthy physical and mental development, a child needs to be well nourished. Addressing the problem of poor knowledge and poor adoption of appropriate maternal nutrition and child feeding practices and new-born care practices is a primary challenge towards reducing chronic child undernutrition or child stunting which negatively influence overall cognitive development and under-five mortality. Recent research estimates 68% of under 5 mortality in India is associated with child malnutrition. A focus on mapping and repeatedly counselling families with pregnant women, newborns and children below 24 months, in rural or urban areas and in low or high wealth index families is essential, for preventing child growth faltering and preventing child undernutrition," says Dr Sheila Vir, Director, Public Health Nutrition and Development Centre, New Delhi.
Targeted, timely focus would facilitate AWWs and ASHAs to ensure that every pregnant woman is registered early for antenatal care (ANC) services, attends at least 4 ANC services and is counselled on regular consumption of iron-folic acid and calcium supplements, ICDS food supplements supplied as Take Home Rations (THR) and on consuming food adequate in proteins and micronutrients by following the practice of diet diversity; every newborn is breastfed within an hour of birth and is fed only breastmilk for the first 6 months of life and every child receives the right immunization; every child crossing six months of age is given age-appropriate complementary feeding.
“Intensified, contextualised and focused counselling also allows room for engaging negotiations on a case-to-case basis. For instance, during home visits, a frontline health worker can open a dialogue about consumption of food groups by the mother and child and suggest easily-sourced or kitchen garden-grown additions that would add to the nutritional value of each meal. During targeted counselling, information about eligibility for public distribution system (PDS), take-home ration (THR), and immunisation drives can also be discussed at length. Topics of significance, like water, sanitation and hygiene, and toilets, are other areas that could benefit from intensified counselling,” says Dr Sebanti Ghosh - Country Program Director, Alive and Thrive, FHI360, a global nutrition initiative to save lives, prevent illness and ensure healthy growth and development through improved maternal nutrition, breastfeeding and complementary feeding practice.
According to Dr. Ghosh, once they adopt the necessary health-promoting behavior by repeated and intensive messaging in the initial touchpoint, further counselling can continue to reinforce it, without the frontline worker having to spendhuge amounts of time for everyone at every point of contact.
As per Dr. Sheila Vir, we cannot ignore the quarter of children in the high-income group or high wealth index category who suffer from undernutrition and stunted growth. Reaching mothers /caregivers right after delivery through personal counselling and mass media and digital media for disseminating correct information and convincing them for adoption of correct breastfeeding practices in the first six months and appropriate introduction of semi-solid foods on completion of 6 months along with continuation of breastfeeding is imperative for prevention of child undernutrition”.
Introducing such a model that ensures targeted and timely counselling of all pregnant and nursing women in the first 1000 days of life is essential. This strategy is incorporated in the POSHAN Abhiyaan program design. However, for effectively rolling out the strategy, efforts need to be directed at mapping households with pregnant women and/or 0-24 months and channelizing intensive efforts towards reducing child undernutrition. Execution of such a plan will take us one step closer to the vision of a malnutrition-free, healthy India by adding interpersonal counselling to the ongoing people-led movement.
